On-Line Proctor Agreement Form

This form is to be filled out and submitted by the individual who will actually be the student's proctor.
Please complete and submit this form using the same computer (or a computer within the same organization) that the student will use to take exams.
Residential computers are not to be used.
All fields should be completed

Before completing this form please read the "Information for Proctors".

Important! A separate form will need to be submitted for each course proctored, HOWEVER, multiple students may be submitted for each course. After the information has been processed you will receive additional information either by U.S. mail or e-mail.

Select the course that you will proctor: 

Student Name(s) followed by the student's email address (e.g. Jane Doe jdoe@someserver.org)
NOTE: One student and email address per line. Press enter after entering each student's name and email address.

 

  Proctor Name:    Job Title:

 Proctor's Employer: Job Department/unit:

Business address:

                 City:  State:   Zip Code:

Proctor Business E-Mail Address:

Proctor business phone number:     Fax Number:

Location that proctoring will occur - Please be as specific as possible. (Please complete and submit this form using the same computer that the student will use to take exams. Residential computers are not to be used.)
(Examples: Newport High School Guidance Office, Des Moines Public Library, Sac County Extension Office):
       

List of times you could be contacted should the need arise. (e.g. Tues and Thru 9am-10:30am) One set per line please.

By clicking the button below I agree to proctor the student(s) named above. This means I will monitor this/these student(s) during test taking making sure no notes or textbooks are used.